COSMETIC The Face Lift SMAS Plication Flap for Reconstruction of Large Temporofrontal Defects: Reconstructive Surgery Meets Cosmetic Surgery Salvatore D’Arpa, M.D., Ph.D. Adriana Cordova, M.D. Roberto Pirrello, M.D. Giovanni Zabbia, M.D. Daniel Kalbermatten, M.D., Ph.D. Francesco Moschella, M.D. Palermo, Italy Background: Reconstruction of large defects in the temporal region can be performed with skin grafts or pedicled or free flaps. Results are often not optimal because of the patch of a skin graft, lack of availability of local flaps, and distant skin from free flaps. A technique for reconstruction of these defects with local tissue is presented in this article that uses superficial musculoaponeurotic system (SMAS) plication to allow wide advancement of a cervicofacial flap. Methods: Once the defect is outlined, a face-lift–like skin incision is used to raise the flap. The SMAS is plicated with two purse-string sutures that relieve tension on the flap and allow maximal advancement. Thirteen face-lift SMAS plication flaps were used in 12 patients (mean age, 70.2 years) after cancer resection, which was bilateral in one case. Defects up to 8 cm in largest diameter can be closed. In one case of an 8  6-cm defect, a 1  1.5-cm skin graft was necessary. Results: All flaps healed uneventfully, and no reoperation was necessary. Scars are almost completely hidden and the cosmetic result is satisfactory. The asym- metrical face-lift effect fades out within 6 months. Conclusions: The face-lift SMAS plication (FLISP) flap allows reconstruction of large defects in the temporal region with a local flap providing an excellent cosmetic result and avoiding the need for distant tissue and multiple scarring. This flap provides an example of how reconstructive surgery and cosmetic surgery are complementary and can be mutually beneficial. (Plast. Reconstr. Surg. 127: 2068, 2011.) R econstruction of large defects of the tempo- rofrontal region after excision of malignant skin tumors is not an easy task. The tightness of the skin (which restricts advancement) and the close proximity to the hairline and the brow (which are not good donor sites for flaps that will bring hair into the defect and cause distortion of either hairline or brow) restrict the number of local options available. For this reason, reconstruc- tion of this area is most commonly performed by using skin grafts, either partial or full-thickness, with less-than-optimal cosmetic results because of the patch effect. Flap reconstruction has been de- scribed but requires multiple scarring from geo- metrically complex local flaps, 1–7 mobilization of the entire forehead, 8 –11 or regional donor sites 12,13 that complicate surgery and give the unpleasant effect of a regional island of skin. These cancers mostly affect elderly people, who have a high degree of skin laxity and tissue ptosis in the midface and lower face. By merging concepts and techniques of cosmetic and recon- structive surgery, the authors have used a cervico- facial rotation advancement flap with superficial musculoaponeurotic system (SMAS) plication for flap reconstruction of large and even very cranial defects of the temporofrontal region. In this ar- ticle, a 12-patient series with a minimum follow-up of 1 year is retrospectively reviewed. PATIENTS AND METHODS From January of 2006 to April of 2009, 12 patients were treated for cancers of the temporo- frontal region that caused large defects needing From the Cattedra di Chirurgia Plastica e Ricostruttiva, Dipartimento di Discipline Chirurgiche ed Oncologiche, Uni- versita ` di Palermo, and Plastic Surgery, University of Basel. Received for publication October 4, 2010; accepted November 8, 2010. Copyright ©2011 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e31820e92a0 Disclosure: The authors have no financial interest to declare in relation to the content of this article. www.PRSJournal.com 2068